Juvenile Idiopathic Arthritis - CHU Sainte-Justine - SAAC

Early radiology signs

Oligoarthritis :differential diagnosisTraumaInfectionHaematologic diseaseVascular malformationOrthopaedic problem

OligoarthritisDo not forget theophtalmologicevaluation!

Polyarthritis5 or more jointsMorning stiffness(> pain)Functionaldifficulties

Epidemiology of JIAIncidence : 9.2 to 13.9 /100.000children per yearPrevalence : 1.13 /1000 childrenMore frequent than JuvenileDiabetes or Cystic Fibrosis

Team ApproachPaediatric RheumatologistPaediatric Orthopaedic SurgeonPhysiotherapistOccupational therapistSocial workerNurse coordinator

Effects of intra-articular steroidsComplication :Sub-cutaneousatrophy

Physiotherapy & O.T.MobilityStrengthContracturesDomestic aids

Indications for SurgeryJust part of the treatmentNot a « punishment »Cannot be «isolated »

Pre-op EvaluationOther joints involved?Upper extremities (crutches)Cervical spineTMJIntubation

Soft Tissue Surgery:TenotomiesPre-opPost-op

Soft Tissue Surgery: SynovectomyVolkmann 1877Techniques:open surgeryarthroscopy (1970)chemicalisotope (CI: growth)

Soft Tissue Surgery:Arthroscopic SynovectomyComplete synovectomyimpossibleRegrowth of abnormal tissueCan be repeatedBetter results in Oligo-A

The hip in JIAThe main drawbackto locomotion30 to 35% of PolyA.80% bilat.Narrowing of jointspace in 75% after 5years of evolution

Osteotomies in JIA

Osteotomies in JIATechnical challenge:StabilizationPromote mobilityExternal fixation (Ilizarov) can beused as an alternative toextensive surgery

Osteotomies in JIA

Arthroplasty in JIATotal hip arthroplasty inpatients younger than 21years: a minimum 10-yearfollow-upB.Bessette,F.Fassier,M.Tanzer, E.BrooksCan J Surg 46, 4, 257-262,2003

Results: SurvivorshipOverall survivorship = 10 /15 or 67%Survivorship in Charnley A = 0/4 or 0%(4 of 5 failures)Survivorship in Charnley C = 10/11 or 90 %

DiscussionSignificantimprovement infunction and quality oflife, especially inCharnley C patientsMeasuring outcome inCharnley C patientsdifficult

Survivorship of the Charnley total hiparthroplasty in juvenile chronic arthritis. Afollow-up of 186 cases for 22 yearsCharnley low-friction arthroplasty (LFA)on 116 patients (186 hips)Overall survival was 91.9% at ten yearsand 83.0% at 15 years.(That of the femoral component was 95.6% at tenyears and 91.9% at 15 years and of the acetabulum95.0% and 87.8%, respectively.)Lehtimaki MY et al, JBJS Br 1997

Total Knee Arthroplasty in Young Patientswith Juvenile Rheumatoid ArthritisParvizi J. et al, JBJS 200325 patients under 20 y (mean age: 17)Average follow-up: 10.7 Y

Total Knee Arthroplasty in Young Patientswith Juvenile Rheumatoid ArthritisResults:The mean Knee Society pain scoreimproved markedly from 27.6 to 88.3points, and the mean Knee Society functionscore improved modestly from 14.8 to 39.2points.A slight improvement in the ROMParvizi J. et al, JBJS 2003

Upper extremity problems

Elbow Synovectomy in JRAThe short-term results of elbow synovectomyin patients with rheumatoid arthritis havebeen satisfactory in 70% to 90% ofprocedures.Approximately 80% of these patients reportrelief of pain at approximately 5 years.Mansat P, Joint Bone Spine 2001

Upper extremity problemsUlnar deviation, acommon problem

Ulnar lengthening in juvenile chronicarthritisUlnar lengthening can be done safely and theprocedure seems to stabilize the carpus, islikely to improve appearance, may improvefunctionIn the majority of cases does eliminate theuse of an external splint.Results seem to be stable for at least 3 to 5years.Mink van der Molen Abet al, J Hand Surg [Br]. 1998

Limb length discrepancyCommon findingDifficult to estimate (FFC)Difficult to followBone age often impossible to determinePrognosis of LLD difficult

Limb length discrepancyThe best treatment: PreventionEpiphyseodesis

Thank youMerci